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University of South FloridaScholar Commons
Graduate Theses and Dissertations Graduate School
July 2018
Teaching Mands to Individuals with AutismSpectrum Disorder: An Evaluation of the Essentialfor Living Communication Modality AssessmentDaniella OrozcoUniversity of South Florida, [email protected]
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Scholar Commons CitationOrozco, Daniella, "Teaching Mands to Individuals with Autism Spectrum Disorder: An Evaluation of the Essential for LivingCommunication Modality Assessment" (2018). Graduate Theses and Dissertations.https://scholarcommons.usf.edu/etd/7345
Teaching Mands to Individuals with Autism Spectrum Disorder: An Evaluation of the Essential
for Living Communication Modality Assessment
by
Daniella Orozco
Thesis submitted in partial fulfillment of the requirements for the degree of
Master of Science Department of Child and Family Studies
College of Behavioral and Community Sciences University of South Florida
Major Professor: Catia Cividini-Motta, Ph.D, BCBA-D Kimberly Crosland, Ph.D, BCBA-D
Raymond Miltenberger, Ph.D, BCBA-D
Date of Approval: June 26, 2018
Keywords: communication modalities, mand training, verbal behavior, alternative and augmentative communication (AAC)
Copyright® 2018, Daniella Orozco
Dedication
A mi hermosa familia, gracias a todos por su constante apoyo incondicional. Gracias por
motivarme a ser la mejor version de mi, todos los días. A mis maravillosos padres, Maytte y
Alejandro, esto nunca lo hubiese podido lograr sin ustedes. Son mi major inspiración! Gracias
por creer en mi en todo momento y por siempre asegurarme de que si lo puedo lograr. Ningún
objetivo es imposible cuando uno está rodeado de personas tan increíbles. Esto es por ustedes, y
gracias a ustedes.
Acknowledgments
I would like to acknowledge my advisor, Dr. Catia Cividini-Motta for her ongoing help
and feedback, making this study possible. I would also like to acknowledge my thesis committee
members, Dr. Kimberly Crosland and Dr. Raymond Miltenberger for their advice and
knowledgeable input towards this study. Lastly, I would like to acknowledge Dr. Claudia
Campos Fleitas for her continuous help and support, throughout this entire process.
i
Table of Contents
List of Tables ................................................................................................................................... ii List of Figures ................................................................................................................................. iii Abstract ........................................................................................................................................... iv Introduction ..................................................................................................................................... 1 Method ............................................................................................................................................. 8 Participants, Settings, and Materials ................................................................................... 8 Response Measurement ....................................................................................................... 9 Reliability of the Observation and Treatment Integrity .................................................... 12 Experimental Design ......................................................................................................... 16 Phase 1:Pre-Asssessments ................................................................................................. 16 Edible Preference Assessments ............................................................................. 16 Communication Modality Preference Assessments .............................................. 16 Essential for Living Communication Modality Assessment ................................. 17 Phase 2: Mand Modality Evaluation ................................................................................. 19 Mand Selection ...................................................................................................... 19 Baseline ................................................................................................................. 19 Mand Training ....................................................................................................... 20 Results……………………..... ...................................................................................................... 23 Discussion ...................................................................................................................................... 33 References ..................................................................................................................................... 37 Appendices .................................................................................................................................... 42 Appendix A: Identifying a Vocal Profile .......................................................................... 43 Appendix B: Testing for Repertoire’s ............................................................................... 44 Appendix C: Task Analysis-Multiple Stimuli Without Replacement Preference Assessment ........................................................................................................................ 45 Appendix D: Task Analysis-Mand Training ..................................................................... 46 Appendix E: Task Analysis- EFL Communication Modality Assessment ....................... 47 Appendix F: Results from the EFL Website that recommends a communication Modality ......................................................................................... …………………….48 Appendix G: Chart that the EFL handbook provides to depict what each letter stands for ...................................................................................................................................... 49 Appendix H: Format of each mode of communication for each participant ..................... 50 Appendix I: USF IRB Approval Letter ............................................................................. 51
ii
List of Tables
Table 1: Average and Range IOA for each Assessment for all Participants ............................. 15 Table 2: Average and Range Treatment Integrity for each Assessment for all Participants ..... 15 Table 3: Summary of results of EFL communication modality and modality preference assessments .................................................................................................................................... 27 Table 4: Summary of the EFL Assessment of Current Repertoire (Percentage of Correct Responding) and of the caregiver interview .................................................................................. 27 Table 5: Summary of the 30-min structured observation for the EFL Assessment of Vocal Profile (Percentage of Correct Responding) and vocal profile identified for each participant ..... 28 Table 6: Summary of the parent interview for the EFL Assessment of Vocal Profile from Appendix A Section II ................................................................................................................... 28
iii
List of Figures
Figure 1: Results for Daphne’s, Daniel’s, and Walter’s Preference Assessments ...................... 20
Figure 2: Results of the first mand training for Daphne, Daniel, and Walter ............................. 30
Figure 3: Results of the second mand training for Daniel, and Walter ....................................... 31
Figure 4: Results for the Communication Modality Preference Assessment for Daphne, Daniel,
and Walter .................................................................................................................................... 32
iv
Abstract
McGreevy, Fry, and Cornwall (2014) developed an assessment within the Essential for
Living (EFL) manual for clinicians to identify which communication modality should be used
for each individual. This assessment identifies an AAC based on the learner’s skills, level of
problem behavior, similarities between AAC and vocal community, and size of the verbal
community. However, to date, no research has evaluated if this assessment identifies the
communication modality that will result in faster acquisition of mands in individuals with ASD.
Thus, the purpose of this study was to compare acquisition of mands across a modality identified
by the EFL communication modality assessment and two other commonly used modalities. A
secondary purpose was to determine if participants acquire mands using the mode of AAC
identified by EFL. Finally, a third purpose was to determine if the communication modality
identified by EFL communication modality assessment matches the modality currently used by
the individual. Findings showed that although all three participants acquired mands across the
three communication modalities, mands in the modality of communication recommended by the
EFL assessment were acquired faster only by 1 out of the 3 participants.
1
Introduction
According to the Center for Disease Control and Prevention (2014), 1 in 68 children are
diagnosed with an autism spectrum disorder (ASD). Moreover, 25 to 35% of individuals with an
ASD have limited speech (Lord & Jones, 2012), which is a common characteristic of the
disorder (Filipek et al., 1999). Individuals who do not have proficient vocal repertoires qualify
for an augmentative and alternative communication (AAC). The AAC used with these
individuals typically consists of picture-based communication systems, manual signs (MS) , or
speech-generating devices (SGDs; Tager-Flusberg & Kasari, 2013; Mirenda, 2003; Wodka,
Mathy, & Kalb, 2013). Although various modes of AAC are available and many individuals
become proficient at using these modes, acquisition of mands for some individuals is very slow
or limited potentially because the mode of AAC assigned or selected for these individuals was
inappropriate. In these cases, behavior analysts may change teaching procedures or the mode of
AAC in attempts to foster acquisition. To date, few methods for selecting an AAC modality are
available. Therefore, additional research on procedures for selecting a method of AAC that is
appropriate and results in acquisition of mands is warranted.
The different modes of AAC can be used to develop a variation of verbal operants, such
as mands, tacts, intraverbal, or echoics. However, in this study, we focused on mands because
they are the basis of all other verbal behavior. Skinner (1957) described the mand as a verbal
operant in which a response is reinforced by a distinctive consequence. Meaning that the
response is under the functional control of similar conditions of deprivation or unpleasant
stimulation. The mand is the verbal operant in which the reinforcer is specified. Moreover, a
2
mand involves requesting access to reinforcer, independent of whether or not it is present.
Furthermore, mands are sometimes classified as pure or impure mands (Skinner, 1957). Mands
that are under the control of the establishing operation (EO; Michael, 1982) are only pure mands.
An impure mand, on the other hand, is controlled by an EO and a vocal (e.g., “What do you
want?”) or a visual (e.g., presence of the item) prompt.
Often, individuals vocally state their wants and needs. However, individuals who have
limited vocal communication skills may express their wants and needs in a different mode of
communication (e.g., picture exchanges, MS, SGDs). Picture exchanges (PE) is a selection-based
communication (Sundberg & Sundberg, 1990) that consists of manual exchanges of pictures
cards that are laminated and are part of a picture exchange book. Pictures may be of different
sizes depending on the characteristics of the users and typically attach to a picture book with
Velcro™. Individuals exchange these pictures to mand for their wants and needs. For example,
Couper et al. (2014), used PE to teach children with ASD how to mand for toys. Their findings
showed that seven out of nine children successfully learned to request for preferred toys using
PE.
Another communication modality that has been evaluated in the literature is MS. Manual
signs are characterized as an unaided communication technique and is considered topography-
based communication. Multiple studies have contributed empirical support for the use of manual
sign manding in generating a functional communication repertoire when there is not any
appropriate verbal behavior (e.g., Gregory, DeLeon, & Richman, 2009; Elias, Goyos, Saunders,
& Saunders, 2008). A limited body of research has also suggested that MS language may
facilitate the development of vocal responding (Schlosser & Wendt, 2008). However, Schlosser
3
and Wendt (2008) suggested that these effects may be narrowed to those children who have
already developed a modest vocal imitation repertoire.
Individuals with an ASD may also be taught to communicate using SGDs. These consist
of a hardware, such as an iPad® or another transportable device, containing an application that
generates speech (e.g., Proloquo®). These devices are becoming progressively prominent and are
sometimes preferred over nonelectronic systems such as Picture Exchange Communication
Systems (PECS; Gevarter et al., 2013; van der Meer, Sigafoos, O’Reilly, & Lancioni, 2011).
Although supplementary research is necessary to determine all variables that affect this
preference, Son, Sigafoos, O’Reilly, and Lancioni (2006) suggested that this preference may be
due to some characteristics of the devices themselves (e.g., shape, color, size, or voice output).
Furthermore, SGDs can be understood by the entire verbal community of the individual. In
contrast, when individuals use other forms of communication (e.g., MS) their effective
communication is limited to the verbal community who understands MS. Moreover, because
SGDs produce a speech output dependent on a communicator-initiated response, the need for a
listener to model a vocal response, such as when using picture exchanges (PE), may be
eliminated. Additionally, SGD-based interventions may result in an increase in independent
vocalizations. For instance, Gevarter et al. (2016) found that for three out of four participants, the
addition of vocal language instructional methods to an SGD-based intervention led to an increase
in independent vocalizations.
Acquisition of an AAC may be affected by factors such as preference, prerequisite skills,
practice opportunities, and response effort (Sigafoos, O’Reilly, & Lancioni, 2006). The
preference and rate of acquisition for MS, PE, and SGDs was compared, using four children with
an ASD, in a study by Van der Meer, Sutherland, O’Reilly, Lancioni, and Sigafoos (2012). The
4
mands were acquired in at least one of the communication modalities, by all four of the
participants. However, the results demonstrated that the individuals attained mastery criteria at
different rates, depending on the type of communication modality used. Additionally, the
participants displayed a preference for the specific modality for which faster acquisition and
better maintenance was obtained. In a similar study, Van der Meer, Sutherland, O’Reilly, and
Lancioni (2012) found that all participants preferred an iPod touch® over PE and MS. Moreover,
all four participants acquired mands with the iPod touch® and the PE, while only two
participants acquired mands with the MS. Moreover, Gevarter et al. (2013), reviewed several
studies evaluating rate of skill acquisition and preference across PE, SGDs, and MS (e.g., Beck
et al., 2008; Bock et al., 2005). These studies suggested that there are benefits in appraising an
individual’s choice for using distinct types of communication devices. However, there are no
studies exploring variables that might have a repercussion on that preference.
Although there are no known variables as to why some individuals prefer one AAC over
another, there are some prerequisites that should be taken into consideration when choosing an
AAC. Tincani (2004) found that for individuals without hand-motor imitation skills, PE might be
the best AAC option for initial mand acquisition. For individuals with limited hand-motor
imitation skills, sign language might be just appropriate to teach. In another study, Gregory et al.
(2009) also found that preexistence of motor imitation and matching skills made a difference in
the acquisition of manual signs and PE. In this study, the three individuals that possessed these
two skills, quickly learned how to use both AAC modalities. In contrast, the other two of three
individuals who did not possess these skills did not acquire the response forms. The last
individual acquired exchange-based responses but not MS.
5
The results from these studies demonstrate that programming developed to teach
communication skills to individuals with an ASD should be individualized and that clinicians
should carefully consider the mode of communication prescribed. Currently, a few methods for
selecting an AAC modality are available. For instance, LaRue et al. (2016) evaluated a model to
identify which communication modality represents the best match for individuals in need of
communication intervention. This model consisted of teaching students to tact using various
AAC modalities to determine which AAC resulted in the fastest acquisition. Their results were
consistent with previous findings demonstrating that individuals have clear preferences for one
modality and that usually the preferred modality is associated with faster acquisition (Van der
Meer et al., 2012).
Bryen, Goldman, and Quinslik-Gill (1988) described an additional method for selecting
an AAC modality known as partner competence. This method emphasizes choosing an AAC that
others in the environment (e.g., teachers, parents, or caregivers) can teach and reinforce
adequately in the natural settings. However, it does not consider the individuals’ current skills.
Another method for selecting a mode of AAC includes observing the communicative needs of
the individual, environmental demands, and contextual characteristics (Jones, Jollef,
McConachie, & Wisbeach, 1990). These procedures consist of assessing the individual’s
mobility, posture, hand function, vision, ocular-motor, hearing, symbolic and verbal
comprehension, and communicative functions and modes. In addition, the procedure stresses that
an undetected problem in one of these areas can lead to the collapse of a planned intervention
program. Thus, it provides a step-by-step assessment that facilitates decision-making during the
selection of an AAC modality. This method is advantageous because it accounts for variability
across skills in different children however this method does not take into considerations other
6
factors that may impact acquisition and use of AAC such as level of problem behavior and size
of verbal community.
Finally, McGreevy, Fry, and Cornwall (2014) published an assessment handbook called
Essential for Living ® (EFL). This handbook is a communication, behavior, functional skills
curriculum, and skills tracking instrument for people with moderate-to-severe disabilities.
Essential for Living can be used to identify deficits in functional skills, develop meaningful goals
and behavior plans, and to keep record of problem behavior as well as skill acquisition.
Additionally, EFL is the first instrument of its sort that is established on concepts, principles, and
procedures from Applied Behavior Analysis and that incorporates speaking and listening skills
that derive from B.F. Skinner’s analysis of verbal behavior (Skinner, 1957). Furthermore, EFL
contains a communication modality assessment that considers the learner’s skills, level of
problem behavior, similarities between AAC and vocal community, and size of verbal
community; it also makes recommendations for primary and secondary modes of AAC. This
method provides guidelines for choosing primary, secondary, back-up, and concurrent methods
of communication. It also provides procedures to identify the efficacy of the chosen method of
communication. In this assessment, an individual is ‘matched’ with distinct methods of
communication modalities based on their current repertoire, each modality of communication’s
overlap with characteristics of vocal communication, and the size of the verbal community.
However, to date, there is no research to support if this assessment identifies a communication
modality that will result in acquisition of mands.
In summary, it is important to teach individuals with little or no functional speech how to
communicate. The EFL communication assessment provides a systematic method for identifying
at least one alternative mode of communication for individuals with disabilities. However, to
7
date, there is no research evaluating this assessment. Thus, the purpose of this study was to
compare acquisition of mands across a modality identified by the EFL communication modality
assessment and two other commonly used modalities. A secondary purpose was to determine if
participants acquired mands using the mode of AAC identified by EFL. Finally, a third purpose
was to determine if the communication modality identified by the EFL communication modality
assessment matches the modality currently used by the individual.
8
Method
Participants, Settings, and Materials
Three children participated in this study. Criteria for participation included a limited
vocal repertoire as reported by caregivers. This information was obtained through a
questionnaire that parents of potential participants completed during the screening process. The
questionnaire asked if the individual used an AAC and if so, which one and how it was selected.
A pseudonym was used for each participant. Daphne was a 4-year-old girl with an ASD. Daphne
used PE as her primary mode of communication and it was selected by her Board Certified
Behavior Analyst (BCBA). She manded for a limited number of items when prompted. Daniel
was a 3-year-old boy with an ASD. Daniel’s primary mode of communication was also PE
selected by his BCBA. He also had a limited communication repertoire consisting of mands for a
few items but these were always prompted. Walter was an 8-year-old boy diagnosed with an
ASD. Walter used an SGD at school and the SGD was selected by his parents. He also only
manded for items when prompted by his caregivers and teachers. At the time of this study, none
of the participants engaged in independent mands.
Sessions were conducted in therapy rooms inside of ABA clinics and in the participants’
homes. For Daphne and Daniel all sessions were conducted at the clinic where they received
ABA therapy. For Daphne, the therapy room was approximately 3 m X 2 m and contained two
tables, three chairs, and a cabinet. For Daniel, the therapy room was approximately 2 m X 2 m.
For Walter some of the sessions were conducted in his bedroom at his house which was
approximately 3 m X 4 m and contained a full size bed, one nightstand, a table, two chairs, a toy
9
bin, and a dresser. Other sessions were conducted in a therapy room at the clinic where he
received ABA therapy. This room was approximately 8 m X 4 m and contained one table, two
chairs, a TV, a ball pit, two beanbag chairs, a play tent, and a couch. Participants were recruited
through flyers posted around USF campus, distributed via email, and sent to ABA agencies that
provided a letter of support. Materials included edibles used during the edible and
communication modality preference assessments and mand training. In addition, we used
different pictures for the PE modality and iPads® programed with ProloquoTM for the SGD
modality. We also used a 7 cm X 10 cm picture of each modality for the modality preference
assessment. The picture for PE consisted of a PE book, the picture for the SGD consisted of an
iPad® with ProloquoTM on the screen, and the picture for MS consisted of the American Sign
Language (ASL) MS for “more”. Paper and pencil were used to record data and a video camera
was used to record some of the sessions.
Response Measurement
During the edible and communication modality preference assessments, data were
collected on the participants’ selections of foods and modes of communication, respectively.
Selection was defined as the participant touching, pointing to, or grabbing one of the items (or
picture) presented in the array within 5 s of the onset of the trial. During the edible preferrence
assessment, data were summarized using a point weighting scoring method similar to the one
described by Ciccone, Graff, and Ahearn (2005). That is, points were assigned to each item
based on the trial in which it was selected during each session of the preferred assessment (e.g.,
if there were 6 trials in one session, trial 1 would result in 6 points, trial 2 would result in 5
points). Then, the scores received by each item in each of the sessions were added together to
give a total score for each item. Items that received 75% or more of the possible points were
10
defined as highly preferred. The results of the communication modality preference assessment
were summarized as percentage of trials during which each mode was selected by adding the
total number of times a communication modality was selected, dividing by the number of trials
that it was available, and multiplying by 100.
During the EFL communication modality assessments, data were collected on the
participants’ current sensory, skill, and behavioral repertoires (e.g., matching, hearing, seeing;
see Appendix B) that matched those recommended for each alternative method of
communication. Each of these responses was operationally defined (see Appendix B). Sessions
consisted of five trials and we collected data on the percentage of trials in which the participant
correctly emitted each target response (e.g., matching, hearing, seeing). If the participant emitted
the target response in at least 80% of the trials in one session we deemed that that skill was part
of the participant’s repertoire.
During the mand modality evaluation, we collected data on the percentage of trials per
session with correct prompted and independent mands as well as errors across the different
communication modalities. Mands were defined as the emission of the target response in the
prescribed modality (e.g., PE, SGD, MS) in the presence of the preferred item and within 5 s of a
vocal prompt “what do you want?” Furthermore, mands were defined for each mode of
communication. For instance, in the PE condition, a mand was defined as the participant handing
the picture depicting the preferred item over to the therapist. For the SGD condition, a mand was
defined as the participant touching the icon corresponding to the preferred item with enough
force to generate audio in the iPad® programed with ProloquoTM. For the MS condition, a mand
was defined as the participant making the MS for the preferred item (e.g., making hands and
fingers into the correct form and placing them in the correct part of the body). An independent
11
mand was defined as any instance in which the participant emitted the correct response in the
correct modality without a prompt (e.g., emitted the correct MS). A prompted mand was defined
as the participant emitting the correct response in the correct modality with a prompt (e.g., using
hand over hand to guide the participant into handing over the correct card). Finally, an incorrect
response was defined as any instance in which the participant did not emit a correct response
(e.g., touched the incorrect icon on the SGD) or did not emit any response within 5 s of the vocal
prompt, “What do you want?” Percentage of trials with independent or prompted mands and
errors were calculated by totaling the number of trials with each type of responses, dividing by
the number of trials during each session, and multiplying by 100.
During the mand selection assessment, data were collected on independent mands as
these data were summarized as percentage of trials with independent mands. During baseline,
data were collected on the participants’ independent mands using each modality until stable
responding or a decreasing trend was observed during the last three sessions. At the beginning of
the session the participants had access to the materials needed for each of the communication
modalities to be assessed during mand training. Each baseline session consisted of 10 trials and
items for which the participant did not emit a mand correctly, in either mode of communication,
were selected for training. To control for difficulty level across communication modalities we
applied the following rules:
1. PE and SGD icons were identical (e.g., same size, pictures of actual object, colored
pictures, same placement of icons)
2. PE and SGD were placed in the same location at the beginning of each session to
control for the response effort required to retrieve the communication device and emit
a mand
12
3. PE and SGD were placed within 0.3 m of the participant
4. Because the target response in PE and SGD required the participant to touch or hand
over one icon, signs taught consisted of one discrete hand movement
Reliability of the Observation System and Treatment Integrity
Graduate students served as therapists and data collectors. Training was delivered in-
person and consisted of behavior skills training (BST; Miltenberger, 2012). Observers had to
obtain 90% or above agreement for a mock session before collecting reliability data.
Interobserver agreement (IOA) was calculated for at least 33% of sessions across all phases for
all participants (see Table 1). The observers independently scored sessions by directly observing
the session or by reviewing recorded footage of the sessions. Across all phases and assessments
IOA was calculated on a trial-by-trial basis by dividing the number of trials with agreement by
the total number of trials and multiplying the results by 100. For the edible preference
assessments IOA was calculated for 40% of sessions for each participant and the mean score was
100% for Daphne, 96% (range, 83-100%) for Daniel, and 100% for Walter. For the
communication modality preference assessment, IOA for Daphne, Daniel, and Walter was
calculated for 50% of the sessions. For Daphne, IOA was 100%. For Diego, IOA was 95%. For
Walter, IOA was 100%. During the EFL communication modality assessment IOA was
calculated for 36% of the assessment sessions. The average IOA for Daphne was 90% (range,
60-100%), and for Daniel and Walter it was 100%. For the first mand training, IOA for Daphne
was calculated for 36% of the sessions and the average IOA was 95% (range, 90-100%). For
Daniel and Walter, it was calculated for 40% of the sessions and the average IOA was 95%
(range, 90-100%) and 97% (range, 90-100%) respectively. For the second mand training, IOA
for Daniel was calculated for 50% of the sessions and the average IOA was 98% (range, 90-
13
100%). For Walter IOA was calculated for 33% of the sessions and the average IOA was 98%
(range 90-100%).
Treatment integrity was assessed for at least 30% of all sessions across all phases for all
participants (see Table 2). A task analysis describing the steps to be completed during each of the
assessments was used. During the edible and communication modality preference assessment
data were collected on whether or not the therapist had all materials necessary, delivered the
correct instructions, provided adequate amount of time for participant to select one of the items,
and provided correct consequences (see Appendix C). For Daphne, Daniel, and Walter, treatment
integrity for the edible preference assessments was collected on 40% of all sessions. For Daphne,
the average treatment integrity was 100%, for Daniel, the average treatment integrity was 96%
(range, 92-100%), and for Walter, the average treatment integrity was 94% (range, 85-100%). In
addition, for Daphne, Daniel, and Walter treatment integrity for the communication modality
preference assessments was collected on 50% of all sessions. For Daphne and Daniel, the
treatment integrity was 100%, for Walter, the average treatment integrity was 96%, During the
EFL communication modality assessment, we evaluated whether the observer had all the
necessary materials, set the occasion for all repertoires’ being evaluated, and provided adequate
amount of time for the individual to engage in the behavior being observed. Treatment integrity
was assessed for 36% of all sessions for Daphne, Daniel, and Walter. Treatment integrity was
100% for all three participants.
We also assessed treatment integrity of the implementation of the procedures during the
mand modality evaluation by using a task analysis that states whether or not the therapist
prompted the participants to emit the correct mands during each trial, provided the item
immediately after the participants engaged in the mand, allowed time for the participant to
14
consume the edible for a maximum of one min. Treatment integrity for the mand selection
assessment was calculated for 33% of the sessions and treatment integrity was 100% for Daphne,
Daniel, and Walter. Combined treatment integrity scores were calculated across baseline and
mand training. For Daphne, it was assessed for 36% of the sessions and the average treatment
integrity was 98% (range, 92-100%). For Daniel, treatment integrity was assessed for 43%, and
the average treatment integrity was 98% (range, 92-100%). For Walter, treatment integrity was
assessed for 38% of the sessions and the average treatment integrity was 99% (range, 97-100%).
15
Table 1. Mean and Range IOA for each Assessment for all Participants
Table 2. Mean and Range Treatment Integrity for each assessment for all participants
First Mand Training Baseline
First Mand Training Treatment
Second Mand Training Baseline
Second Mand Training Treatment
Vocal Profile Structured Observation
Repertoire Structured Observation
Mand Selection
Edible PA Communication modality PA
Daphne
Daniel
100% on 33% of sessions 95% (range, 90-100%) on 40% of sessions
93% (range, 90-100%) on 38% of sessions 95% (range, 90-100%) on 40% of sessions
N/A 95% (range, 90-100%) on 50% of sessions
N/A 100% on 50% of sessions 95%(range, 90-100%) on 33% of sessions
60% on 33% of sessions 100% on 33% of sessions
100% on 38% of sessions 100% on 38% of sessions
100% on 33% of sessions 100% on 33% of sessions
100% on 40% of sessions 96% (range, 83-100) on 40% of sessions
100% on 50% of sessions 95% on 50% of sessions
Walter
97% (range, 90-100%) on 38% of sessions
97 (range, 90-100%) on 43% of sessions
100% on 33% of sessions
100% on 33% of sessions
100% on 38% of sessions
100% on 33% of sessions
100% on 40% of sessions
100% on 50% of sessions
16
Experimental Design
A nonconcurrent multiple probe (Horner & Baer, 1978) across participants with an
adapted alternating treatments design was used in this study. We compared acquisition of mands
across three communication modalities (e.g., PE, MS, and SGD). Training was staggered across
participants. Training began with Daphne when three probes with each modality were completed
and data were on a stable trend. Training began with Daniel when Daphne had acquired at least
one of the mands and it began with Walter when Daniel had acquired at least one of the mands.
Mands were assigned to one of the communication modalities in a semi-random manner. All
mands selected for the mand modality evaluation were for items that received at least 75% of the
points during the preference assessments.
Phase 1: Pre-Assessments
Edible Preference Assessments. Preference assessments were conducted for all
participants to identify preferred items to use during the mand modality evaluations. Items used
during the preference assessments were identified through the Reinforcer Assessment for
Individuals with Severe Disability (RAISD; Fisher, Piazza, Bowman, & Amari, 1996) that were
completed by caregivers, a member of the clinical team, or both. We conduced multiple stimuli
without replacement preference assessments (MSWO; DeLeon & Iwata, 1996) for all
participants. Items that received 75% or more of the possible points were selected for the mand
modality evaluation.
Communication Modality Preference Assessment. Preference assessments were
conducted for all participants to assess whether they had a preference towards either of the
communication modalities used during mand training. These were completed before and after the
mand training assessment and consisted of a trial-based preference assessment method. Prior to
17
conducting choice trials of the preference assessments trials, we completed a series of five
exposure trials for each of communication modalities. In addition, we completed two forced
exposure trials immediately prior to each preference assessment session. During forced exposure
trials participants were prompted to use the communication modality by using hand-over-hand
prompting and mands resulted in access to the specific item. During the choice trials the three
communication modalities were placed in a row on the table approximately 0.3 m in front of the
participant and 0.1m apart from each other. In addition, pictures of each of the modalities were
placed in front of the participant and the participant was instructed to choose one. Upon
selection, the participant was given an opportunity to mand for the corresponding preferred item
and then access to that item was provided.
The three communication modalities were available during each trial and data were
collected on which mode the participant selected. The initial preference assessment trials were
embedded within the sessions of the mand selection. That is, at the beginning of each mand
selection trial we presented the participant with the pictures of the three modes of
communication, allowed the participant to make a selection, then completed that trial of the
mand selection session. This process was repeated until we completed 10 choice trials. For the
remainder of the mand selection session, during each subsequent trial, just one mode of
communication was presented to the participant. The final preference assessment was completed
following mand training and consisted of 10 choice trials.
Essentials for Living Communication Modality Assessment. The EFL communication
modality assessment was conducted as following: First, we identified a vocal profile for each of
the participants based on the six vocal profiles provided by the EFL. This vocal profile was
selected based on the individuals’ spoken-word repertoire. This consisted of evaluating if the
18
individual had any spoken words and if they did, evaluating if these words were spontaneous,
understandable, frequent, or a combination of these. The observer also evaluated if the
individuals’ spoken word repetition was controlled, uncontrolled, understandable, or a
combination of these. For this part of the assessment, we conducted an interview with the parents
(see Appendix A, Section I) and we conducted a 30-min structured observation (see Appendix A,
Section II). We then selected an alternative method of communication for participants whose
vocal profile was in the range of three to six. If participants fell in between two vocal profiles,
we selected the highest vocal profile (e.g., if they fell in between vocal profiles 2 and 3, we
selected vocal profile 3).
The alternative method of communication was selected by evaluating the following
sensory, skill, and behavioral repertoires: hearing, sight, walking, activity level, fine motor
coordination, motor imitation, matching, and level of problem behavior. Observers evaluated
these repertoires by conducting an interview with the parents (see Appendix B, Section I) and
conducting a 30-min observation (see Appendix B, Section II). Individuals were then matched to
an alternative method of communication by comparing their current repertoire to that
recommended by the EFL handbook for each of the communication modalities. As per the EFL,
we also considered the advantages and disadvantages of each alternative communication
modality in comparison to vocal communication (e.g., portability, effort, complexity,
communication skills) and the size of the person’s verbal community for each of the potential
AACs. We selected an AAC by first choosing the modality with the most repertoire matches. If
more than one modality had the same number of matches, we then selected the modality that was
most similar to vocal communication (e.g., same advantages). If we still had more than one
modality, we then selected the modality with the largest audience. Finally, if necessary, we
19
considered caregiver and clinician preference and AAC availability in selecting a mode of AAC
for the participant. Once we identified an alternative mode of communication based on the EFL
assessment, we selected two other commonly used modes. Examples of common practice AACs
include SGD, PE, MS, and the Picture Exchange Communication System (PECS, Charlop,
Carpenter, LeBlanc, & Kellet, 2002).)
Phase 2: Mand Modality Evaluation
Mand selection. Once preferred items were identified, we assessed whether the child
manded independently for these items using any of the chosen modalities of communication. For
this assessment all preferred items were available but out of reach of the participant. The session
lasted until each participant had 10 opportunities to mand with each of the communication
modalities. However, during the first 10 trials, the participant was allowed to choose one of the
communication modalities as previously described under the communication modality
preference assessment. A trial began when the therapist presented the preferred edible, within
eyesight but out of reach, to the participant. If the participant did not make a request within 5 s,
the therapist delivered a vocal prompt, “if you want something, please let me know”. The
participant was given 30 s to make a request and then another trial began. An opportunity to
mand was scored when the participant attempted to access one of the items, the participant used
the communication mode to attempt to request the item, and anytime the therapist delivered the
vocal prompt, “if you want something, please let me know”. Items for which no independent
mands were emitted in any mode of communication were selected for the mand training. Mands
were assigned to one of the communication modalities in a quasi-random basis.
Baseline. During baseline, all communication modalities were randomly paired with a
specific mand. Each session consisted of 10 trials. At the beginning of each trial, the therapist
20
ensured that the participant had access to the target communication modality (e.g., PE, MS, or
SGD), presented the preferred item at the end of the table in front of the participant but out of
reach, and a vocal prompt (e.g., “What do you want?”). The participant’s manding repertoire
with each of the different communication modalities was assessed in different sessions and the
sequence in which the communication modalities were presented was semi-random. This was
done by writing on a piece of paper the name of each communication modality and placing the
pieces of paper inside of a bag. The observer then picked a piece of paper from the bag and a
session of the selected modality was conducted. After one session had been completed for each
communication modality, the pieces of paper were returned to the bag and the process was
repeated. If the participant emitted the correct response, the item was provided to the participant
until the item was consumed. All sessions were terminated after 10 trials had been completed.
No programmed consequences were provided for problem behavior. However, if no correct
responding was emitted, praise was provided for appropriate session behavior every three trials
in an attempt to minimize the likelihood of problem behavior occurring due to an extended
period without access to reinforcers. Items with low levels of independent responding (no more
than 20% of trials) during baseline were selected for mand training.
Mand training. We conducted the mand training evaluation once for Daphne, and twice
for Daniel and Walter. We used most-to-least prompting to teach all mands across the three
communication modalities. The communication modalities used during this evaluation were PE,
MS, and SGDs (See Appendix H). Mand training sessions were completed separately for each
mode of communication and the sequence was presented semi-randomly as described in
baseline. During mand training sessions the preferred item was continuously available during the
session, within view but out of reach of the participant. Sessions included 10 trials and each trial
21
began either with a vocal prompt, “What do you want?”, or when the participant initiated a mand
for the preferred item, without the vocal prompt. For the PE and SGD, after 10 s had passed, if
the participant had failed to respond correctly, the observer physically prompted the participant
to use the communication modality appropriately by using hand-over-hand physical prompting,
and reinforced the behavior immediately after completing the mand. Hand-over-hand prompts
were faded into gesture prompts which consisted of the therapist touching the correct icon on the
PE or SGD. Similarly, for the MS sessions, after 10s had passed, the observer physically
prompted the participant to make the appropriate sign by using hand-over-hand prompting.
Hand-over-hand prompts were faded into gesture prompts which consisted of the therapist
pointing to the participant’s body part that the participant was required to touch to emit the
correct sign (i.e., cheek when the MS was candy). Criterion to fade prompts was at least 50%
independent mands in one session. If the participant independently manded for the preferred
item, no prompting was used. Therapists reinforced all prompted and independent mands
immediately after they were emitted. The participant was provided with a piece of an edible item
until they consumed it. After the participant consumed the item, the next trial started. Errors
resulted on removal of all session materials and then a full prompt to emit the correct response.
No reinforcers were delivered for mands emitted during the error correction procedure. Mastery
criteria was two sessions with at least 90% correct and independent mands. However, once
mastery criteria was met for one modality, additional sessions were completed to ensure that
performance of the mastered mand persisted and to determine whether, given additional training
sessions, the participant would acquire the other mands. Thus, we conducted mand training
sessions until each participant acquired mands across all 3 modes of communication.
22
Picture exchange (PE; see Appendix H). During this condition, a picture(s) of the
target mand was placed in front of the participant and was centered on the table 0.3 m away. For
Daphne, a picture of Smarties® was used for the mand training. For Daniel, a picture of
Smarties® was used for the first mand training and a picture of M&M® was used for the second
mand training. For Walter, a picture of Candy Corn® was used for the first mand training and a
picture of Smarties® was used for the second mand training.
Speech generating device (SGD; see Appendix H). In this condition, the participants
had access to their SGD which consisted of an iPad® with the Proloquo® application. At the
beginning of sessions, the application was opened and the screen showed the page containing the
icon of the target mand. The iPad® was placed centered on the table 0.3 m away from the
participant. For Daphne, an icon of gummies was used for the mand training. For Daniel, an icon
of Starburst® was used for the first mand training and an icon of Swedish Fish® was used for
the second mand training. For Walter, an icon of Sour Patch® was used for the first mand
training and an icon of Skittles® was used for the second mand training.
Manual sign (MS; see Appendix H). No additional materials were present during this
condition. For Daphne, Skittles® were used for this modality and she had to perform the
American Sign Language MS for candy. For Daniel, Candy Corn® was used for the first mand
training, Skittles® were used for the second mand training, and he had to perform a modified
version of the American Sign Language MS for candy to mand for both of these items. For
Walter, Starburst® were used for the first mand training and he had to perform the MS for candy.
Nutter Butter® was used for the second mand training and he had to perform the MS for cookie.
23
Results
Results for Daphne’s, Daniel’s, and Walter’s preference assessments are depicted in
Figure 1. Smarties®, Skittles®, and gummies were used for Daphne’s mand training because
they were the three items that received at least 75% of the points. Unfortunately, Daphne moved
away before the experiment finished. Thus, we did not conduct a second preference assessment
with her. Two preference assessments were conducted with Daniel and Walter to identify at least
six preferred items to be used during the initial mand training and the mand training replication.
For Daniel, Candy Corn®, Starburst®, and Smarties® were used for the first mand training and
Swedish Fish®, M&M®, and Skittles® were used for the second mand training because these
were the items that were obtained at least 75% of the points. For Walter, gummies, Candy
Corn®, and Starburst® were used for the first mand training and Sour Patch®, Nutter Butter®,
and Starburst® were used for the second mand training because they obtained 75% of the points.
During the EFL communication modality assessment we first identified each participant’s
vocal profile. This was done based on the data attained through the caregiver interview and the
structured observation of each of the participants (see Table 5 & 6). Parents reported that
Daphne, Daniel, and Walter could say 5-10, 5-10, and 10-15 words respectively and that these
were spontaneous. In addition, Daphne, Daniel, and Walter spoke these words 10-15, 5-10, and
10-15 times per day respectively but that unfamiliar people did not always understand them. All
three participants repeated these words in a nonfunctional way, and their word repetition was not
understandable by unfamiliar people. According to the interview, only Daniel was able to control
these non-functional spoken-word repetitions. Finally, all three participants could hear, see, were
ambulatory, active, had fine motor imitation, could match pictures to objects, and did not have
24
problem behavior. However only Walter had fine motor coordination. Results of the structured
interview are shown in Table 4. None of the participants emitted any of the target responses
during the observation. Therefore, based on their vocal repertoire they were classified as Vocal
Profile 4, which is defined by the EFL as “Uncontrolled or Controlled Spoken-Word Repetitions
are not understandable”.
Results of the assessment of sensory, skill, and behavioral repertoires are shown in Table
4. All three participants had similar characteristics and repertoires. They were all able to see and
hear, were active and ambulatory, and did not engage in problem behavior. Daphne and Walter
had fine motor imitation and matching skills but neither had fine motor coordination. Daniel did
not have fine motor coordination, fine motor imitation, or matching skills. Alternative modes of
communication were then selected using http://amscompare.com. For each participant we
indicated which skills they had in their repertoire such as seeing, hearing, imitation, ambulatory,
matching, fine motor, as well as problem behavior. The results of the EFL communication
modality assessment are shown in Appendix F. The EFL communication modality assessment
recommended MS for all three participants.
During the mand selection evaluation, none of the participants emitted independent
mands for the preferred edibles. These mands were therefore selected for mand training. Figure 2
depicts results for Daphne, Daniel, and Walter for the first mand training comparison. During
baseline, there were zero levels of independent mands across all communication modalities for
Daphne and Daniel. For Walter there were zero to 20% independent responding levels across all
communication modalities. In contrast, with the implementation of mand training, there was an
increase in the percentages of independent mands across all communication modalities for all
participants. For Daphne, MS was the mode recommended by the EFL assessment and the mode
25
in which she acquired mands in fewer sessions. Daphne met mastery criteria for all three
modalities within eight mand sessions of combined modalities. For Daniel, MS was the mode
recommended by the EFL. By contrast, SGD was the mode he acquired in fewer training
sessions. Daniel met mastery criteria in all three modalities within ten training sessions of
combined modality. Finally, for Walter, MS was also the mode recommended by the EFL. By
contrast, PEs was the mode he acquired in fewer training sessions. Walter met mastery criteria in
all three modalities within seven training sessions of combined modalities. Moreover, for both,
Daniel and Walter, MS required the most number of sessions to mastery.
Figure 3 depicts results for Daniel and Walter for the second mand training
comparison. Daphne was not included in this evaluation because she moved away before this
evaluation could be completed. For Daniel and Walter, results were similar to the first mand
training evaluation and we were able to see a faster acquisition of mands since they developed a
repertoire of generalized mands. During baseline independent mands were at zero to low levels.
Moreover, with the implementation of mand training, percentage of independent mands
increased until mastery criteria was met for all three modalities. For Daniel, SGD was again
acquired in fewer training sessions. However, unlike the results of the first mand training
comparison, MS and PE were acquired in the same number of training sessions. Mastery criteria
for all three modalities was met within four training sessions of each condition. For Walter, in
contrast to the first mand training evaluation where PE required fewer sessions, SGD was
acquired first. However, only one additional training session was required to meet mastery
criteria for PE. Similarly to the first comparison, acquisition of MS required the most training
sessions. Walter required a total of six training sessions of each condition to meet mastery
criteria for all three modalities.
26
Results from the communication modality preference assessments for all participants are
shown in Figure 4. Daphne preferred SGD both before and after training even though MS was
the mode acquired in fewer training sessions. Prior to training Daniel preferred MS. In contrast,
the AAC modality preferred after training was SGD and this was the modality acquired in fewer
training sessions. Finally, prior to training Walter did not show a preference towards any of the
AAC modalities. After training, he demonstrated a stronger preference for the modality in which
he acquired mands in fewer sessions, PE.
Table 3 includes a summary of the EFL communication modality assessment,
communication modality preference assessment, mand modality evaluation, and each
participant’s primary mode of communication prior to enrolling in this study. Daphne was using
PE prior to the study, however, the EFL communication modality assessment recommended MS.
By contrast, Daphne preferred the SGD before and after training even though she acquired
mands using MS faster. Daniel was using PE prior to the study and the EFL communication
modality assessment also recommended MS. Daniel preferred MS before and after the mand
training even though he acquired mands using SGD faster. Walter was using an SGD prior to the
study and the EFL communication modality assessment also recommended MS. Walter did not
have a preference before mand training. However, after mand training, he preferred PE which
was the modality for which he had faster acquisition of mands.
27
Table 3. Summary of the Results of the EFL Communication Modality and Modality Preference Assessments.
AAC Modality
Prior to study Per EFL Preferred
Pre-trg Mastered
First Preferred Post-trg
Daphne PE MS SGD MS SGD
Daniel PE MS MS SGD MS
Walter SGD MS N/A PE PE
Table 4. Summary of the EFL Assessment of Current Repertoire (Percentage of Correct Responding) and of the caregiver interview
28
Table 5. Summary of the 30-min structured observation for the EFL Assessment of Vocal Profile (Percentage of Correct Responding) and vocal profile identified for each participant
Table 6. Summary of the parent interview for the EFL Assessment of Vocal Profile from Appendix A Section II
1. Mands for
preferred edible (within sight)
2. Mands for preferred toy (within sight)
3. Functional vocal
response
Vocal
Profile
Daphne 0 0 0 4
Daniel 0 0 0 4
Walter 0 0 0 4
1. Does your child say any words?
2. If yes, how many?
3. Are these words spontaneous?
4. How many times a day does your child say these words?
5. Are these words understandable by people who don’t know your child?
6. Does your child repeat words?
7. Does your child emit these nonfunctional spoken-word repetitions at appropriate times?
8. When your child repeats words, do people who do not know your child understand these words?
Daphne Yes 5-10 Yes 10-15 Yes Yes Yes No
Daniel Yes 5-10 Yes 1-5 No Yes Yes No
Walter Yes 10-15 Yes 10-15 No Yes No No
29
Edible
Figure 1. Results for Daphne’s, Daniel’s, and Walter’s preference assessment. The Y-axis represents cumulative points that each edible received. The X-axis depicted the items available during the preference assessment. The horizontal line indicates items that obtained 75% of the total points.
30
Figure 2. Results of the first mand training for Daphne, Daniel, and Walter. The Y-axis represents the percentage of independent mands during baseline and mand training. The X-axis represents days in which sessions were conducted. Open triangles represent independent mands emitted using a SGD. Open circles represent independent mands emitted using PE. Closed squares represent independent mands emitted using manual signs.
31
Figure 3. Results of the second mand training for Daniel, and Walter. The Y-axis represents the percentage of independent mands during baseline and mand training. The X-axis represents days in which sessions were conducted. Open triangles represent independent mands emitted using a SGD. Open circles represent independent mands emitted using PE. Closed squares represent independent mands emitted using manual signs.
32
Figure 4. Results for the communication modality preference assessment for Daphne, Daniel, and Walter. Black bars area depicts percentage of trials in which the modality was chosen during the preference assessment completed before mand training. Grey bars depict percentage of trials in which the modality was chosen during the preference assessment completed following mand training. Symbol above bars indicate the AAC modality that was acquired in fewer sessions.
33
Discussion
This study sought to compare acquisition of mands across a modality of communication
recommended by the EFL communication modality assessment and two other commonly used
modalities. Prior to the study, Daphne and Daniel used PEs and Walter used a SGD. However,
the EFL communication modality assessment recommended MS for all three participants.
Therefore, skill acquisition of mands was compared using MS, PE, and SGD. All three
participants acquired the three modalities, however, they did so at different rates. Daphne
acquired MS first, SGD second, and PE last. Daniel acquired SGD first, PE second, and MS last.
Walter acquired PE first, SGD second, and MS last. For Daniel, results were replicated in the
second mand training. Daniel acquired the SGD faster than the other modalities in the first and
second mand training. For Walter, results from the mand training comparisons were very similar.
In addition, another aim of this study was to determine if participants acquired mands
using the mode of AAC identified by EFL communication modality assessment. This was the
case for all three participants as they acquired mands using the modality of communication
recommended by the EFL assessment, MS. Lastly, this study sought to determine if the
communication modality recommended by EFL communication modality assessment was the
same as the modality the participants were using prior to enrolling in this study. This was not the
case for any of the current participants as the EFL assessment recommended MS for all three and
prior to our study Daphne and Daniel were using PE and Walter was using a SGD, respectively.
34
In the current study, Previous research has also investigated the correspondence between
preference for communication modality and rate of acquisition. For instance, Van der Meer et al.
(2012) evaluated acquisition and preference of MS, PE, and SGD in four children with ASD.
Mands were acquired in at least one of the communication modalities by all four participants.
However, results indicated that depending on the type of communication modality used,
participants reached mastery criteria at different rates. They found that all participants had faster
skill acquisition with an iPod touch® and that they preferred the iPod touch® over PE and MS
Similarly, Beck et al. (2008) and Bock et al. (2005) also compared skill acquisition of mands and
results suggested that there are advantages in considering an individual’s choice for using
distinct types of communication devices.
This study also extended on Tincani (2004) which found that PE might be the best AAC
option for initial mand acquisition for individuals without hand-motor imitation skills. In this
study, Walter did not have fine-motor coordination and PE was the modality that he acquired the
fastest.
This study extended the current research on methods for selecting communication
modalities. Previous research tested a model that consisted of teaching students to tact using
various AAC modalities to determine which AAC resulted in the fastest acquisition (LaRue et
al., 2016). Another study used partner competence, which is a method that emphasizes choosing
an AAC that can be taught and reinforced by others (e.g., caregivers) in a natural setting (Bryen,
Goldman, & Quinslik-Gill, 1988). Thus this appears to be the first study to assess the
correspondence between acquisition rate of the mode of communication recommended by the
EFL communication modality assessment and other commonly used modes of communication.
In this study, all three participants had similar characteristics and MS was recommended for all
35
three by the EFL communication modality assessment, however, only Daphne acquired mands
faster using this modality. Moreover, all three participants acquired the three modalities but each
participant had a different modality that resulted in faster acquisition. Therefore this may not be a
feasible mode of AAC selection and additional research needs to be done since the recommended
AAC was not always acquired faster.
Despite its noteworthy contributions to the literature on procedures for selecting
communication modalities, the current study has a few limitations. First, Daphne moved before
the experiment had concluded so we were not able to conduct a second mand training
comparison with her. Second, this study only had three participants and all three participants had
similar characteristics and pre-requisite skills. Therefore, generality of the results are limited to
similar participants. Future research should extend by using more participants to determine the
generality of these findings. Third, participants acquired all mands in similar number of
sessions, thus conclusions about different rate of acquisition are limited. Perhaps future research
should teach more complex mands. In addition, IOA scores for one of the assessment sessions
was 60%. This happened during one of Daphne’s vocal profile structured observation sessions.
This session was only 5 trials, and it assessed whether she manded for preferred items. For this
session, the primary observer selected no for all 5 trials. In contrast, the second observer selected
yes for 2 of the trials potentially because she was Daphne’s ABA therapist and had more
exposure to her. However, the participant had to obtain 80% or higher in the session in order to
account as having the skill, and the primary observer scored 0% while the second observer
scored 40%. Furthermore, mand training included the question “what do you want?” so we
taught impure mands, however previous research assessing acquisition with mands with our
without the inclusion of the “what do you want?” prompt has not found a difference in rate of
36
acquisition (Bowen, Shillinsburg, Carr, 2012). Furthermore, in our attempt to control for
difficulty level across modalities only a few aspects of the AAC devices and training format
were addressed. Future research should also ensure that PE and SGD have the same number of
icons and perhaps that the same icons are presented in both AACs. Moreover, for Daniel the
same MS (candy) was used for both mand trainings because two different types of candy were
found to be highly preferred for him. This was an error in selecting a MS for the second mand
training comparison. Future research should ensure to target different MS across mand training
evaluations. Lastly, the experimental design delayed implementation of sessions. Thus future
research should focus on using a different experimental design to evaluate if it has a difference in
the acquisition of mands.
In summary, the results of this study indicate that the EFL Communication Modality
Assessment may not be a valid way of identifying an effective mode of communication since
results showed that the mode identified by the EFL Communication Modality Assessment was
not the best, based on speed of acquisition for two out of the three participants. Thus, this study
adds to the literature by evaluating a new systematic method for clinicians to select a mode of
communication. However, additional research is needed to compare how this assessment would
work differently with individuals who have different characteristics and do not share the same
pre-requisite skills as the participants in this study.
37
References
Barlow, D. H., & Hayes, S. C. (1979). Alternating treatments design: One strategy for comparing
the effects of two treatments in a single subject. Journal of Applied Behavior Analysis,
12, 199-210. doi:10.1901/jaba.1979.12-199
Beck, A. R., Stoner, J. B., Bock, S. J., & Parton, T. (2008). Comparison of PECS and the use of a
VOCA: A replication. Education and Training in Developmental Disabilities, 43, 198–
216.
Bock, S. J., Stoner, J. B., Beck, A. R., Hanley, L., & Prochnow, J. (2005). Increasing functional
communication in non-speaking preschool children: Comparison of PECS and VOCA.
Education and Training in Developmental Disabilities, 40, 264-278
Bondy, A. S., & Frost, L. A. (1994). The picture exchange communication system. Focus on
Autistic Behavior, 9, 1-19. doi:10.1177/108835769400900301
Bryen, D. N., Goldman, A. S., & Quinslik-Gill, S. (1988). Sign Language with students with
severe/profound mental retardation: How effective is it? Education and Training in
Mental Retardation, 23, 129-137.
Centers for Disease Control and Prevention. (n.d.). Autism information center. Retrieved April 1,
2017, from http://www.cdc.gov/ncbddd/Autism/
Ciccone, F. J., Graff, R. B., & Ahearn, W. H. (2005). An alternate scoring method for the
multiple stimulus without replacement preference assessment. Behavioral Interventions,
20(2), 121-127. doi:10.1002/bin.177
38
Couper, L., Meer, L. V., Schäfer, M. C., Mckenzie, E., Mclay, L., O’Reilly, M. F.,
Sutherland, D. (2014). Comparing acquisition of and preference for manual signs,
picture exchange, and speech-generating devices in nine children with autism
spectrum disorder. Developmental Neurorehabilitation, 17, 99-109.
doi:10.3109/17518423.2013.870244
DeLeon, I. G., & Iwata, B. A. (1996). Evaluating of a multiple-stimulus presentation format for
assessing reinforcer preferences. Journal of Applied Behavior Analysis, 29, 519-532.
doi:10.1901/jaba.1996.29-519
Doss, S., & Reichle, J. (1991). Replacing excess behavior with an initial communicative
repertoire. In J. Reichle, J. York, & J. Sigafoos, (Eds.), Implementing Augmentative and
Alternative Communication (pp. 215-237). Baltimore: Paul H. Brookes.
Elias, N. C., Goyos, C., Saunders, M., & Saunders, R. (2008). Teaching Manual Signs to Adults
With Mental Retardation Using Matching-to-Sample Procedures and Stimulus
Equivalence. The Analysis of Verbal Behavior, 24, 1-13. doi:10.1007/bf03393053
Filipek, P. A., Accardo, P. J., Baranek, C. T., Cook, E. H. Jr, Dawson, G., & Gordon, B. (1999).
The screening and diagnosis of autistic spectrum disorders. Journal of Autism and
Developmental Disorders, 29, 439-473.
Fisher, W.W. Piazza, C.C., Bowman, L.G., & Amari, A. (1996). Integrating caregiver report
with a systematic choice assessment. American Journal on Mental Retardation, 101, 15-
25.
Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, L. P., Owens, J. C., & Slevin, I. (1992). A
comparison of two approaches for identifying reinforcers for persons with severe and
39
profound disabilities. Journal of Applied Behavior Analysis, 25, 491-498.
doi:10.1901/jaba.1992.25-491
Gevarter, C., O’Reilly, M. F., Kuhn, M., Mills, K., Ferguson, R., Watkins, L., & Lancioni, G. E.
(2016). Increasing the vocalizations of individuals with autism during intervention with a
speech-generating device. Journal of Applied Behavior Analysis, 49, 17-33.
doi:10.1002/jaba.270
Gevarter, C., O’Reilly, M. F., Rojeski, L., Sammarco, N., Lang, R., Lancioni, G. E., &
Sigafoos, J. (2013) Comparing communication systems for individuals with
developmental disabilities: A review of single-case research studies. Research in
Developmental Disabilities, 34, 4415-4432. doi:10.1016/j.ridd.2013.09.017
Gregory, M., DeLeon, I., & Richman, D. (2009). The influence of matching and motor-
imitation abilities on rapid acquisition of manual signs and exchange-based
communication responses. Journal of Applied Behavior Analysis, 42, 399-404.
doi:10.1901/jaba.2009.42-399
Jones, S., Jollef, N., McConachie, H., & Wisbeach, A. (1990). A model for assessment of
children for augmentative communication systems. Child Language Teaching
and Therapy, 6, 305-321. doi:1177/026565909000600306
LaRue, R. H., Pepa, L., Delmolino, L., Sloman, K. N., Fiske, K., Hansford, A., Weiss, M. J.
(2016). A brief assessment for selecting communication modalities for individuals with
Autism Spectrum Disorders. Evidence-Based Communication Assessment and
Intervention, 10, 32-43. doi:10.1080/17489539.2016.1204767
Lord, C., & Jones, R. M. (2012). Annual Research Review: Re-thinking the classification of
40
autism spectrum disorders. Journal of Child Psychology and Psychiatry, 53, 490-509.
doi:10.1111/j.1469-7610.2012.02547.x
McGreevy, P., Fry, T., & Cornwall, C. (2014). Essential for Living: a communication, behavior
and functional skills assessment, curriculum and teaching manual for children and adults with
moderate-to-severe disabilities. Orlando, FL: Patrick McGreevy
Michael, J. (1982). Distinguishing between discriminative and motivational functions of stimuli.
Journal of the Experimental Analysis of Behavior, 37, 149-155. doi:10.1901/jeab.1982.37-149
Miltenberger, R. G. (2012). Behavior modification: Principals and procedures (5th ed.). Pacific
Grove, CA: Wadsworth
Mirenda, P. (2003). Toward a functional augmentative and alternate communication for students
with autism: Manual signs, graphic symbols, and voice output communication aids. Language,
Speech, and Hearing Services in Schools, 34, 203-216. doi:10.1044/0161-1461(2003/017)
Pace, G. M., Ivancic, M. T., Edwards, G. L., Iwata, B. A., & Page, T. A. (1985). Assessment of
preference and reinforcer value with profoundly retarded individuals. Journal of Applied
Behavior Analysis, 18, 249-25. doi:10.1901/jaba.1985.18-249
Paclawskyj, T. R., & Vollmer, T. R. (1995). Reinforcer assessment for children with
developmental disabilities and visual impairments. Journal of Applied Behavior Analysis,
28, 219-224. doi:10.1901/jaba.1995.28-219
Roane, H. S., Vollmer, T. R., Ringdahl, J. E., & Marcus, B. A. (1998). Evaluation of a brief
stimulus preference assessment. Journal of Applied Behavior Analysis, 31, 605-620.
doi:10.1901/jaba.1998.31-605
Schlosser, R., Blischak, D. M., & Koul, R. (2003). Roles of speech-output in AAC. In R.
Schlosser (Ed.), The efficacy of augmentative and alternative communication:
41
Toward evidence-based practice (pp. 471-532). San Diego: Academic Press.
Schlosser, R., & Wendt, O. (2008). Effects of augmentative and alternative
communication intervention on speech production in children with autism: A
systematic review. American Journal of Speech-Language Pathology, 17, 212-230.
doi:10.1044/1058-0360(2008/021)
Sigafoos, J., & Iacono, T. (1993). Selecting augmentative communication devices for persons
with severe disabilities: Some factors for educational teams to consider. Australian and
New Zealand Journal of Developmental Disabilities, 18, 133-146.
doi:10.1080/07263869300034901
Skinner, B. F. (1957). Verbal behavior. Acton, MA: Copley.
Son, S. G., Sigafoos, J., O’Reilly, M., & Lancioni, G. E. (2006). Comparing two types of
augmentative and alternative communication systems for children with autism. Pediatric
Rehabilitation, 9, 389-395. doi:10.1080/13638490500519984
Sundberg, C. T., & Sundberg, M. L. (1990). Comparing topography-based verbal behavior with
stimulus selection-based verbal behavior. The Analysis of Verbal Behavior, 8(1), 31-41.
doi:10.1007/bf03392845
Tager-Flusberg, H., & Kasari, C. (2013). Minimally verbal school-aged children with autism:
The neglected end of the spectrum. Autism Research, 6, 468-478. doi: 10.1002/aur.1329
Tincani, M. (2004). Comparing the picture exchange communication system and sign language
training for children with autism. Focus on Autism and Other Developmental Disabilities,
19, 152-163.
42
Touchette, P. E., & Howard, J. S. (1984). Errorless learning: reinforcement contingencies and
stimulus control transfer in delayed prompting. Journal of Applied Behavior Analysis,
17, 175-188. doi:10.1901/jaba.1984.17-175
Van der Meer, L., Sigafoos, J., O’Reilly, M. F., & Lancioni, G. E. (2011). Assessing
preferences for AAC options in communication interventions for individuals with
developmental disabilities: A review of the literature. Research in Developmental
Disabilities, 32, 1422-1431. doi:10.1016/j.ridd.2011.02.003
Van der Meer, L., Sutherland, D., O’Reilly, M. F., Lancioni, G. E., & Sigafoos, J. (2012). A
further comparison of manual signing, picture exchange, and speech-generating devices
as communication modes for children with autism spectrum disorders. Research in
Autism Spectrum Disorders, 6, 1247-1257. doi:10.1016/j.rasd.2012.04.005
Watson, P. J., & Workman, E. A. (1981). The non-concurrent multiple baseline across-
individuals design: An extension of the traditional multiple baseline design. Journal of
Behavior Therapy and Experimental Psychiatry, 12, 257-259.
Weitz, C., Dexter, M., & Moore, J. (1997). AAC and children with developmental disabilities. In
S. Glennen & D. DeCoste (Eds.), Handbook of augmentative and alternative
communication (pp. 395-431). San Diego, CA: Singular.
Windsor, J., Piche, L. M„ & Locke, P. A. (1994). Preference testing: A comparison of two
presentation methods. Research in Developmental Disabilities, 15, 439-455.
doi:10.1016/0891-4222(94)90028-0
Wodka, E. L., Mathy, P., & Kalb, L. (2013). Predictors of phrase and fluent speech in children
with autism and severe language delay. Pediatrics, 131(4). doi:10.1542/peds.2012-2221d
43
Appendices
Appendix A: Identifying a Vocal Profile
Section I – Questionnaire
1. 1. Does your child say any words? YES NO
2. 2. If yes, how many words does your child say? 1-5 words 5-10 words 10-15 words More than 15 Other _______
3. Are these words spontaneous? YES NO
4. How many times a day does your child say these words?
1-5 times 5-10 times 10-15 times More than 15 Other _______
5. Are these words understandable by people that do not know your child?
YES NO
6. Does your child have repeat words in a nonfunctional way?
YES NO
7. Does the child control these nonfunctional spoken-word repetitions?
YES NO
8. Are their spoken-word repetitions understandable by people who do not know your child?
YES NO
Section II – Structured Observation
1. When withholding a preferred item from the child, does the child ask for it if he/she wants it?
YES NO
2. When playing/using a toy/preferred item without the child, does the child spontaneously come up to you and ask for the toy/item?
YES NO
3. Did the child engage in any vocal responses (e.g., words) during the observation period?
YES NO
44
Appendix B: Testing for Repertoire’s
Section I- Repertoire Questionnaire Can your child hear? Yes No Can your child see? Yes No
Is your child ambulatory? Yes No Is your child Active? Yes No
Does your child have fine motor coordination? Yes No Does your child have fine motor imitation? Yes No Can your child match pictures to objects? Yes No
Does your child have any problem behavior? Yes No Section II- Repertoire Structured Observation
Testing for hearing
When playing a cartoon video, does the child follows the sounds in 80% of trials?
Yes No
Testing for Sight
When showing preferred item, does the child looks at it in 80% of trials?
Yes No
Testing for ambulatory
Does the child walk to get to preferred item in 80% of trials?
Yes No
Testing for active
Does the child grab or give any items? Yes No
Testing for fine motor
coordination
When asking a child to trace, string a bead, or put shapes through a shape cube, can the child do this
independently in at least 80% of trials?
Yes No
Testing for fine motor imitation
When shown a fine motor task, the child imitates within 5 s in at least 80% of trials?
Yes No
Testing for matching
When giving the child flashcards of shapes, animals and colors to match, can the child do this independently in at least 80% of trials?
Yes No
Testing for problem behavior
When withholding access to preferred item, did the child cry, whine, scream or display any other
inappropriate behavior?
Yes No
45
Appendix C: Task Analysis- Multiple Stimuli without Replacement Preference Assessment
Collect data on at least 33% of trials per sessionSteps Trial1
Y N NR
Trial2
Y N NR
Trial3
Y N NRTrial4
Y N NR1. Sit across from child 2. Place all items on table in a straight line 3. Items are placed 0.2 meter apart and 0.1 meter away
from participant
4. Tell the child to pick one 5. Does not provide additional prompts 6. Give child 5 s to make a selection 7. If child selects an item, remove the other 8. If child selects more than 1 item, remove both,
represent trial
9. If child does not select an item, remove both,
represent trial
10. When child selects an item allow child to consume edible or play with toy for 30s
11. While the child is consuming the edible or playing with the toy, move the leftmost item over to the rightmost position
12. Do not replace the chosen item in the array 13. Record data on item selected
TOTALSCORE
46
Appendix D: Task Analysis- Mand Training
Tg
Collect data on at least 33% of trials per session
Steps Trial 1
Y N NR
Trial 2
Y N NR
Trial 3
Y N NR
1. Ensure all materials are ready
2. Sit across from child
3. Place preferred item out of child’s reach but within eyesight
4. Wait for child to show interest towards the item (e.g., look at it, reach for it, point at it)
5. Provide Vocal prompt: “What do you want?
6. Provide correct prompt (Full prompt at 0s delay or full prompt at 5 s delay)
7. Reinforce correct response
8. Allow participant to consume edible or play with toy for 30 s
9. If child makes an error, implement error correction (remove items, present trial at full prompt with 0s delay)
10. Do not reinforce mands emitted during error correction
11. Do not provide any programmed consequences for problem behavior
12. Record data after reinforcing mand or conducting error correction
TOTAL SCORE
47
Appendix E: Task Analysis: EFL Communication Modality Assessment
Collect data on at least 33% of trials per session
Steps Trial 1 Trial 2 Trial 3 Trial 4
1. Ensure all materials are ready _____________________ _____________________ _____________________
2. Set environment as needed for skills being assessed:_____________________ _____________________
_____________________
3. Provide at least 30 s for individual to engage in behavior being observed
4. Provide appropriate consequence for problem behavior; see below
5. Do not provide any consequences for errors
6. Do not prompt
7. Provide5opportunitiesfortargetbehavior
8. Recorddataoneachskillbeingassessed
TOTAL SCORE
List problem behavior for each participant and appropriate consequence
48
Appendix F: Results for Daphne, Daniel, and Walter from the EFL website that
recommends a communication modality based on the individual’s current repertoire
49
Appendix G: Chart that the EFL handbook provides to depict what each letter stands for.
50
Appendix H: Format of each mode of communication for each participant
Participant Communication Modality Definition of Correct Response
Daphne
SGD: Ipad® with ProloquoTM application that contained 9 icons
The participant touching the icon corresponding to the preferred item with enough force to generate audio in the iPad® programed with ProloquoTM
PE: Laminated picture board with an “I want” sentence strip at the top, with Velcro attached to it and 4 laminated pictures with Velcro
The participant placing the picture of the preferred item on the sentence strip next to the “I want” icon. The participant was not required to hand the sentence strip to the therapist
MS: No additional materials were present, only the edible was placed in front of the participant
The participant making the MS for the preferred item (e.g., making hands and fingers into the correct form and placing them in the correct part of the body)
Daniel
SGD: Ipad® with ProloquoTM application that contained 9 icons
The participant touching the icon corresponding to the preferred item with enough force to generate audio in the iPad® programed with ProloquoTM
PE: Picture book with Velcro attached to it, and 10 laminated pictures with Velcro
The participant handing the picture depicting the preferred item over to the therapist
MS: No additional materials were present, only the edible was placed in front of the participant
The participant making the MS for the preferred item (e.g., making hands and fingers into the correct form and placing them in the correct part of the body)
Walter
SGD: Ipad® with ProloquoTM application that contained 9 icons
The participant touching the icon corresponding to the preferred item with enough force to generate audio in the iPad® programed with ProloquoTM
PE: Laminated picture board with an “I want” sentence strip at the top, with Velcro attached to it and 4 laminated pictures with Velcro
The participant placing the picture of the preferred item on the sentence strip next to the “I want” icon. The participant was not required to hand the sentence strip to the therapist
MS: No additional materials were present, only the edible was placed in front of the participant
The participant making the MS for the preferred item (e.g., making hands and fingers into the correct form and placing them in the correct part of the body)
51
Appendix I: USF IRB Approval Letter
2/7/2018 Daniella Orozco ABA-Applied Behavior Analysis Tampa, FL 33612 RE:
Expedited Approval for Initial Review
IRB#: Pro00032938 Title: Teaching Mands to Individuals with Autism Spectrum Disorder: An Evaluation of the
Essential for Living Communication Modalities Study Approval Period: 2/6/2018 to 2/6/2019
Dear Ms. Orozco: On 2/6/2018, the Institutional Review Board (IRB) reviewed and APPROVED the above application and all documents contained within, including those outlined below.
Approved Item(s): Protocol Document(s): Study Protocol
Consent/Assent Document(s)*: Parental Consent .pdf informed consent**
*Please use only the official IRB stamped informed consent/assent document(s) found under the "Attachments" tab. Please note, these consent/assent documents are valid until the consent document is amended and approved. **Verbal consent is not stamped.
It was the determination of the IRB that your study qualified for expedited review which includes activities that (1) present no more than minimal risk to human subjects, and (2) involve only procedures listed in one or more of the categories outlined below. The IRB may review research through the expedited review procedure authorized by 45CFR46.110 and 21 CFR 56.110. The research proposed in this study is categorized under the following expedited review category:
